Provider Demographics
NPI:1093134496
Name:RED LEAF NATURAL HEALTH CLINIC
Entity Type:Organization
Organization Name:RED LEAF NATURAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAINA
Authorized Official - Middle Name:MONET
Authorized Official - Last Name:LASSE
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-754-8175
Mailing Address - Street 1:833 SW 11TH AVE STE 1018
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2124
Mailing Address - Country:US
Mailing Address - Phone:503-224-2525
Mailing Address - Fax:503-224-3397
Practice Address - Street 1:833 SW 11TH AVE STE 1018
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2124
Practice Address - Country:US
Practice Address - Phone:503-224-2525
Practice Address - Fax:503-224-3397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1524208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty